Provider Demographics
NPI:1881121176
Name:WICKER, MELANIE ANN (PTA, COTA/L)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:ANN
Last Name:WICKER
Suffix:
Gender:F
Credentials:PTA, COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10886 GRANGE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80233-3841
Mailing Address - Country:US
Mailing Address - Phone:303-748-4247
Mailing Address - Fax:
Practice Address - Street 1:12285 PECOS ST
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80234-3439
Practice Address - Country:US
Practice Address - Phone:303-280-4444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-17
Last Update Date:2017-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0000747224Z00000X
CO0012059225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0000747OtherCOTA
CO0012059OtherPTA